Health Insurance Woes

May 26, 2009 1:32 PM

Our daughter's back was broken when a 67 foot dead ash tree fell on her in a public park. HAP (Health Alliance Plan), our insurance company, is deliberately delaying review of authorization for her to see her neurosurgeon until after her appointment tomorrow. What do we do?

Our daughter's spine was broken in four places a month ago. She went to an excellent hospital and was seen by an excellent neurosurgeon who specializes in trauma and minimally invasive surgery. Our insurance company, HAP (Health Alliance Plan), has delayed approval of her authorization to see this neurosurgeon for followup care - they have suggested that we take her to either of two much less qualified neurosurgeons - random people who do not specialize in trauma or minimally invasive surgery, who know nothing of her care and who do not have a practice anywhere near us or near her college campus. Obviously, initially we are paying for this visit ourselves, but what if she needs the surgery? I don't think we could pay for that. We are appealing, although that will not happen in time for this appointment. What happens if they turn us down? Why are they doing this? Is this common practice in health insurance, and will we eventually be approved?

posted by clarkstonian to health & fitness (31 answers total)

Have you talked to the park management service at all? When I worked for a state government agency, they were always paying for all manner of accidents that occurred on their property.

From dealings with my HMO, seeing someone who they didn't recommend was 'out of network' and, for me, impossibly expensive. Check your plan details.
posted by anti social order at 1:46 PM on May 26, 2009

Does HAP have an ombudsman? Stating that the Dr. who did the surgery is familiar with the case may get you somewhere. Unless the Dr. is not in their plan.
posted by Gungho at 1:50 PM on May 26, 2009

i would be talking to a lawyer about negligence on the part of the public park.

many good people are loathe to start a law-suit - but in this case, especially if proper medical care is not otherwise possible, a law-suit may indeed be in order. all you want is for your daughter to get proper medical care - a lawyer can help you with that. either by dealing with the insurance company, or getting the money from the negligent parks department

talk to a lawyer!
posted by Flood at 1:55 PM on May 26, 2009 [2 favorites]

I don't know if they have an ombudsman. That's a good idea. They have a woman at a fairly high level who, when I initially explained the case, was crying and said nothing was too good for my baby (when they screwed up another aspect of her care). She said if I had any problems at all, to call her, and she would take care of it personally. When I called her back, she wasted an entire day of the authorization process telling me to go call my primary care physician - who is very good and started on the paperwork immediately.

We've been getting snatches of sleep here and there for the past month, so we're not thinking too clearly. Day to day care is pretty much all-consuming. Maybe we should call the park department. We live in a state that pretty much denies any responsibility for anything, but this was pretty clearly their fault.
posted by clarkstonian at 2:00 PM on May 26, 2009

I am not a lawyer. Years ago a guy who worked at our place was driving home during a storm and a tree fell on his car killing him. That large tree, which was alongside the highway shoulder, had been designated a few weeks before to be cut down because it was rotten. The guys family sued and won, because the county hadn't cut the tree down in a timely manner knowing full well it was a risk to fall. She won. I'd consult a lawyer if for nothing else, consultation for somebody to pay (not you) for your daughter to receive the treatment she deserves from the doctor best qualified.

I'm sure your insurance company are doing this because it is the least expensive way to them, which in turn, may not be in your daughters best interest. They should be working with you, not against you.

You shouldn't be paying for a thing. IMO whoever owns the park should be.
posted by Taurid at 2:11 PM on May 26, 2009

Some thoughts...

1) Definitely see about getting the park department to accept liability. I'm torn between calling yourself or calling a lawyer first, though, because if in fact they are resistant, getting your phone call might buy them time to do who knows what to make your case more difficult. So perhaps running this by a lawyer first is advisable.

2) Is this an HMO plan? That's what it sounds like to me, since the plan is asking for authorization to go see a specialist. You could call HAP and ask what would happen if the neurosurgeon they are directing you to see ends up referring your daughter to your current neurosurgeon. Would they accept that more readily? I'd also be looking into what, exactly, her PCP's referral said - it could be that the PCP's office didn't make a good enough case for referring your daughter to this particular neurosurgeon.

3) Has your preferred neurosurgeon's office been of any help? The people who request authorizations have had to appeal denials before - see if that office is willing to fight this along with you. Mention this to your NS at the appointment tomorrow, or ask to speak to the person who handles his/her referrals.

4) Keep pushing for an ombudsman or patient advocate at HAP.

Best of luck to you and your daughter.
posted by DrGirlfriend at 2:17 PM on May 26, 2009

clarkstonian, I'm sorry your family is going through this.

I would strongly advise that you speak with a reputable personal injury attorney (not the ones you see on TV - ask around, and someone you know will probably be able to recommend someone). I strongly suspect that the park management will have some culpability in this, and that damages will be due to your daughter -- however, beyond that, a good attorney can help you navigate dealing with the insurance company, plus lots of other assistance you didn't know they could provide. For example, following my accident last October my attorney was able to contact my mortgage company and utilities to get a three month suspension of payments until I was able to return to work. Most personal injury attorneys will work on contingency -- meaning that if there is not a settlement, they don't get paid.
posted by anastasiav at 2:18 PM on May 26, 2009

We've been getting snatches of sleep here and there for the past month, so we're not thinking too clearly... Maybe we should call the park department.

No. You need to call a lawyer; they will contact the Parks Department.

I understand you're not thinking clearly, and you have all my sympathy for what sounds like a very difficult situation. You are focused on getting though each day but you need to think long term here. Your daughter may need long term care and you are clearly barely treading water here with no idea where the shore is.

Hint: the shore is the Park Department's insurance company, not yours. You need to speak to a litigator, not the Parks Department.
posted by DarlingBri at 2:23 PM on May 26, 2009

This is a similar situation - the tree had been dead for years at the top of a hill. It was killed by Emerald Ash borer, was on a path where college students walked - so the park seems clearly negligent. There weren't even any warning signs that the path was unsafe. I was told they would be in touch with us a month ago. They never called. We are going to talk to a lawyer tomorrow, but lawsuits take time.

Tomorrow's visit will cost about $1,000.00. I can't begin to guess what the surgery would cost. I don't think we could pay for it upfront, hoping to recoup the costs later. I don't understand how the insurance company benefits by denying an 18-year-old proper care. It's pretty clear that this circumstance is extraordinary. We can't just let her be seen by some random doctor who doesn't know anything about her and doesn't specialize in her injury. She's going to need months, maybe years, of physical therapy. We can't go through this same situation every single time for every single thing.

Does anyone work for a health insurance company - is there a way to deal with this? Their seeming total indifference just boggles my mind.
posted by clarkstonian at 2:30 PM on May 26, 2009

I have been thinking about your story since I read it, and posted a response above. You have my deepest sympathy.

But I want to strongly re-state my initial response - call a lawyer!
You need to talk to a tort lawyer. Most tort lawyers work on fees based upon any settlement - the initial consultation with a tort lawyer is ussually free. And they tell you in no time flat if you have a case.

You need a lawyer
posted by Flood at 2:34 PM on May 26, 2009

Yes, the family needs a lawyer but realistically, that will not solve the problem in that the appointment is TOMORROW, per se:

Option 1: Call ahead of the appointment, tell them you have insurance matters to arrange, can they make an exception and allow you to hold over the bill rather than pay in full at the appointment. They will probably do that. Then, you can lawyer up and deal with the financial aspect later on.

Option 2a: I recently had a minor back problem and the orthopedist I preferred from past experience and family relationship was not in network at his office. He was in network through his association with the local hospital, though, and when I advised my insurer (Oxford) of that fact they agreed to treat my office visits with him as in network.

Option 2b: Regarding the same incident, the only physical therapists in-network were several miles away. The one my doctor wanted me to see was right in town. I explained that the others were too far because the actual driving was so painful I needed to be closer, and that while mileage seemed close, traffic made in a 20-30 minute drive. They approved my desired PT as in-network for a certain number of sessions.

If they turn down the claim, it shouldn't be a big deal. I am a lawyer, but obviously cannot and am not commenting on the merits of your case. But it seems to me you have a strong likelihood of obtaining reimbursement for all medical expenses as a result of legal action.

I'm terribly sorry you are having to interrupt time that could be spent with your daughter caring for her, or sleeping to re-up your own coping mechanisms for this trauma, in order to deal with insurance problems. I wish you the best, and please feel free to MeMail or gmail me if you want help getting a referral for a good lawyer, or if you just need to vent. Please accept my hope and prayers for your daughter's health and recovery.
posted by bunnycup at 2:51 PM on May 26, 2009 [7 favorites]

Clarkstonian, one of my former jobs was working as a legal secretary for an attorney who was hired by insurance companies to defend hospitals and lawyers accused of malpractice.

Very few of that attorney's cases went to trial. The overwhelming majority of them were settled by the insurance company.

Most plaintiffs' attorneys in this case work on contingency, meaning you may have to pay them nothing. Very often said attorneys will even swallow their "office expenses" (photocopying, messenger, subpoena fees, etc.) for which they'd otherwise bill the client.

You need to concentrate on finding a good attorney who can help shepherd you through this process. This is unfortunately one of those times where the best route out of your situation lies through the conduit of legal action.

And, needless to say, I am so very sorry that your daughter was injured, and I send you good thoughts for her recovery.
posted by WCityMike at 2:57 PM on May 26, 2009

I don't understand how the insurance company benefits by denying an 18-year-old proper care

That much, at least, is simple. They have your premiums. If they can work out a way not to pay you anything, they get to keep them.

Insurance companies have their shareholders' best interests at heart, not yours. That's why the only sane arrangement for medical insurance is a single, government-run insurance organization: shareholders = customers = total citizenry, and premiums are (as a component of taxation) compulsory for everybody and therefore as low as they can possibly be.

Given that the country where you live doesn't have sane arrangements for medical insurance, your only realistic option is indeed to lawyer up and recover your medical costs from the negligent party instead of fighting with your insurer.
posted by flabdablet at 3:15 PM on May 26, 2009 [4 favorites]

I would strongly advise that you speak with a reputable personal injury attorney (not the ones you see on TV - ask around, and someone you know will probably be able to recommend someone).

Absolutely. I practice this area of law, and while I am fairly certain you are not in the jurisdiction where I practice, it is very common for us to liase with insurance companies on behalf of our clients. We are frequently successful in advocating for a better level of care than the insurer would otherwise provide (if by virtue of nothing else than familiarity with the system). Most of these cases are taken on a contingency fee agreement, so the upfront cost to you is minimal or nil.

The sooner you talk to a good injury lawyer, the better.

(IANYL, TINLA)
posted by AV at 4:10 PM on May 26, 2009

I'm really surprised that your HMO isn't already going after the Parks Department for liability. They want to avoid paying out (obviously) and the obvious people to go to are those who may be liable legally if it were to be pursued. A lot of lawyers will do a free consult because they work on contingency (they get $ if you win).
posted by ishotjr at 4:23 PM on May 26, 2009

check your MeFi mail.
posted by gursky at 4:38 PM on May 26, 2009

Do NOT talk to the Parks Department any longer. Call a lawyer first thing tomorrow. Talk to a FEW before you go with one. Don't even write any more details on this site.
posted by barnone at 4:45 PM on May 26, 2009

flabdablet writes "That much, at least, is simple. They have your premiums. If they can work out a way not to pay you anything, they get to keep them."

Besides being able to dodge the expense for as long as possible, there by collecting interest etc. on what they'd pay out; there is also always the chance the patient could die either from their injuries or even better from their point of view from some other mis-adventure. If your daughter gets hit by a bus in the month they are jacking you around then they've just saved a swack load of money.
posted by Mitheral at 5:35 PM on May 26, 2009

Why are they doing this?

Because they have a book/flowsheet/computer program that tells them that Dr Surgery isn't on their list of approved doctors, and that Dr Faraway and Dr Otherguy are. It's hard to get them off the sheet.

Is this common practice in health insurance, and will we eventually be approved?

Oh Jesus, yes, this is common. I can walk through some of the major insurer's flowsheets for certain procedure approvals in my sleep. I know what key words to use to get things approved.

Will you be approved? Damn good question. This all depends on, as I've said before in the thread about heart transplant on the blue, having the right doctors say the right things in letters and on the phone.

She went to an excellent hospital and was seen by an excellent neurosurgeon...

This guy, or his group, can help. Within our group, the way someone gets to keep seeing us (out of staters, usually) is when the docs write a letter themselves. He needs to write a letter explaining to the insurance company why it is important that your daughter has 'continuity of care' and that the services he can provide are more effective, cost-efficient in the long run, less likely to leave her with a disability, or whatever he can think of as justification. Obviously, this can't be done tomorrow. I suggest bringing it up - very briefly - at the visit and possibly leaving a message with his secretary/office assistant.

And seconding what Bunnycup says, and nthing the Lawyer Up.
posted by cobaltnine at 5:48 PM on May 26, 2009 [4 favorites]

Lawyer, definitely. If you're worried about the costs of a lawyer and all the medical needs, setup a PayPal or TipJoy account and ask for some help on the net. Seriously, don't be "above charity" (if you're usually of that ilk), if you need it, when it comes to your daughter's health care. As others say, though, the park will probably have to pay if there was true negligence on their part.

I hope your family can get some rest and peace soon. Dealing with loved ones' health issues is upsetting enough, but when you've got insurance companies and lawyers to deal with, too, it all makes it that much more difficult.
posted by metalheart at 5:58 PM on May 26, 2009

i just want to add- if you're looking for a reputable lawyer quickly, you could try calling your state's bar association for a recommendation. i did this when i was in need of a personal injury lawyer a few years ago and it seemed to work out well.
posted by genmonster at 6:01 PM on May 26, 2009

From my Mom who worked for doctors offices processing their insurance claims. Her thoughts:
1. You don't know if you will approved or not right now. This is common and the insurance company is going to fight you on this because they want to save money. Remember, insurance companies are for profit organizations and they don't want to have to pay out for the really big stuff if they can avoid it.
2. Continue with the appeal. In the letter of appeal, nicely point out that no one in the insurance office is familiar with her case. However, this neurosurgeon does. Point out that distance, doctor qualifications and experience do not make sense for these doctors to care for your daughter. By referring her to the good doctor, the quality of care for your daughter will be improved, the chance of doctor error is reduced, thus the chance for a malpractice suit is reduced and potentially the overall cost of care for her is reduced. Do not threaten the insurance, however, state that you will be consulting a lawyer to protect her rights to the services to which she is entitled and for which they have been paid. Get in touch with the lawyer.
3. Document everything and keep copies. Get the letter that cobaltnine suggests.
4. Seven to ten business days after appealing, follow up and push the issue. Resubmit the documentation, including any additional bits.
5. Expect to pay for tomorrow's visit. If they approve, submit for reimbursement.
6. Work closely with doctor's staff. The person who does their insurance claims can help you.

Best wishes for your daughter's recovery.
posted by onhazier at 7:15 PM on May 26, 2009 [1 favorite]

Are you in California? If so, you can complain to the Dept of Managed Health Care. If you're not in CA, maybe your state has a similar program?
posted by jasper411 at 8:16 PM on May 26, 2009

I wanted to emphasize one of the points onhazier makes. You should document everything -- every correspondence, every telephone call, every bill, every statement made to you. Note the date, time, person's name, company name, and details for each entry. Do this for all parties (your insurance company, your lawyer if that's what you choose, the Parks Department, their insurance company if it goes to them, the doctors, and anyone else that gets involved).

You are worried and tired, but this is critical and will help you regardless of where your situation leads (to a lawsuit, working it out through the Parks Department, or working it out through your insurance company). It doesn't have to be fancy (a folder and a notebook will work fine), but it's really important to keep track of every single interaction with all the parties involved.
posted by Houstonian at 1:42 AM on May 27, 2009 [2 favorites]

Seconding and thirding both onhazier and Houstonian. Keep track of all costs you incur. Whether its for gas, food, overnights stay, health care, medication, whatever. Even any work that had to be missed by you or any family member. Keep records and receipts. I was in an bicycle/auto accident years ago and all my expenses were reimbursed. You may think it doesn't mean much now, but be diligent. You shouldn't be out a penny. It may take some time, but keep the records. Anything financial. Maybe keep a log or journal too. I should have said this in my earlier comment.

A good lawyer will set the wheels in motion very quickly. Mine did. And thats in your daughters best interest.

"the tree had been dead for years at the top of a hill. It was killed by Emerald Ash borer, was on a path where college students walked - so the park seems clearly negligent.".

...if this isn't negligence, what is?

Good luck to you and your family.
posted by Taurid at 9:59 AM on May 27, 2009

We are going to talk to a lawyer tomorrow, but lawsuits take time.

Tomorrow's visit will cost about $1,000.00. I can't begin to guess what the surgery would cost. I don't think we could pay for it upfront, hoping to recoup the costs later.

Yes, lawsuits take time. However, in my case, my attorney gave each of my doctors, the hospital, labs, etc. a thing called a "letter of protection" which is, in essence, an agreement b the doctor to wait until the claim settles before asking for payment.

I have $50K plus in medical bills that will be paid when my claim settles. To date, I have not paid a dime and I'm not in collection (despite the accident being in October).

Please, please get a lawyer. Having a lawyer to advocate for you and your daughter, to deal with the insurance company, and to be an advocate for you, will reduce the stress in your life ten-thousand fold.
posted by anastasiav at 10:56 AM on May 27, 2009

I stumbled on this and wanted you to know I'd be willing to assist you in any way I can. I am an advocate with HAP. My primary responsibility is to assist our members. I'd like to assist you and answer the questions you posed. If you can email me any relevent information at [e-mail], I'll make sure that you receive timely answers that are in the best interest of your daughter. I'm very concerned that no one here has had direct contact with you or does not understand your needs. Please contact me as soon as possible.
posted by HAPListens at 6:11 AM on May 28, 2009 [1 favorite]

Call HAPListens to see what they can do about this particular coverage issue, but call a lawyer, too. Please call a lawyer, and do not just deal with the insurers and the parks commission yourself. Please please please.
posted by palliser at 12:18 PM on May 28, 2009 [2 favorites]

A very smart, experienced attorney once told me that most people think when they buy insurance that premium payments entitle them to collect on a valid claim, when in reality what they are buying is the right to negotiate with an insurance company...
posted by Hovercraft Eel at 3:30 PM on May 28, 2009 [3 favorites]

Followup - HAP denied our daughter's claim after she saw the doctor - then approved it. As far as we know, her health care is now covered. We have been working with an attorney. Our daughter is healing. It is slow. She's in the full body & leg brace for another month. Once they come off, we'll see where we are.

Advice from several MeFites was invaluable. Thank you everyone!
posted by clarkstonian at 8:44 PM on June 27, 2009

For the record: did HAPListens (a) listen (b) help?
posted by flabdablet at 3:08 PM on June 28, 2009